Beruflich Dokumente
Kultur Dokumente
C O M
Gender Evaluation
of the Doctors of the World and Mdicos del Mundo
Ebola response in Moyamba Ebola Treatment Center Project
Moyamba District, Sierra Leone march 2016
Gender Evaluation
of the Doctors of the World and Mdicos del Mundo
Ebola response in Moyamba Ebola Treatment Center Project
Moyamba District, Sierra Leone march 2016
Acknowledgments
To Mama Salone and its powerful women, for teaching me, once
again, the meaning of the word SISTERHOOD.
Table of Contents
Acknowledgments
Table of Contents
List of Tables
List of Graphics
List of Acronyms
EXECUTIVE SUMMARY
10
12
Methodology
13
GENDER CONTEXT
15
FINDINGS
23
Infrastructure
23
25
28
DISCHARGE
29
Staff
30
EDUCATION
30
ORIGIN
31
32
LEADERSHIP
34
USE OF TIME
35
37
40
CONCLUSIONS
42
RECOMMENDATIONS
44
References
46
Annexes
47
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 5
List of Tables
Table 1
13
13
15
Table 4
16
Table 5
21
Table 6
42
Table 2
Table 3
List of Graphics
Figure 1
18
Figure 2
18
33
Figure 3
19
33
Figure 4
19
34
Figure 5
19
34
21
34
22
35
Figure 8
23
Figure 9
24
36
36
36
37
37
37
Figure 6
Figure 7
24
Figure 11 D
o you think there were cases of sexual
harassment/violence/abuse inside the ETC?
24
26
26
27
27
27
28
38
30
38
31
38
31
39
39
40
40
40
31
31
Figure 23 How did you find out about the job in the
ETC?
32
32
33
33
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 7
List of Acronyms
AcF
CHO
DERC
DFID
DHMT
DOTW
ETC
EVD
FSU
IHP
IPC
MdM
MsF
NGOs
Non-Governmental Organizations
PSS
Psychosocial
RC
Red Cross
SMP
SOPs
StC
WHO
media, etc.
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 9
EXECUTIVE SUMMARY
Sierra Leones first Ebola case occurred in late May 2014 and
public health emergency was declared on 31 July, worsening
the pre-existing structural, social and economic vulnerabilities in
women and girls. Due to Ebola, women and girls are even more
vulnerable than before. There has been a significant increase in
female-headed households, with a large number of dependents
and no income.
Women account for 55 to 60 percent of the deceased in the
current epidemic in Liberia, Guinea and Sierra Leone, according to
UNICEF.
As in many other infectious diseases, no specific or appropriate
treatment for female and male patients has been studied during
the Ebola outbreak. Not only sociological and gender factors have
not been taken into account in the EVD, neither the biological
differences between women and men in the medical treatment.
In this health emergency the medical side has been prioritized,
regardless of cultural, social and anthropological issues. The
influence they have in the transmission and spread of the
disease, in the recovery of patients and in their emotional and
psychological wellbeing after the convalescence have not been
taken into account.
There has been a lack of gender perspective in the Ebola
Treatment Centres (ETCs) infrastructures. Only the medical part
was taken into account to design and build the ETC: patients
were separated according their health status but not by sex, so in
the same ward there were men and women together disregarding
the cultural practices and taboos. No anthropological approach
was used for construction or later for admission of patients.
Regarding sensitization campaigns and according to some local
organizations interviewed, women were not involved either; in
summary, women participation has been very low during the Ebola
outbreak.
Data coming from WHO gives the figure of 278 Ebola cases in
Moyamba District: 149 male (53, 5%) and 129 female (46%).
The distribution of female cases has a spike between the ages
of 15-40, which correlates with the age group most associated
with caregiving in the communities. The number of female positive
cases in Moyamba surpassed the number of males by 19%.
This may be related to several causes: the limited participation of
women in sensitization campaigns, their lack of information about
how the disease is transmitted, their decision-making capacity
about whether to look or not for health care and to the fact that
they only go to the health services when the diseases is more
advanced.
Most of the employees in the ETC come from Moyamba District
and from the same chiefdoms and villages. This is clearly
related to the language challenges both patients and staff were
facing while trying to communicate ones with each other. The
communication gap has been exacerbated in the case of women,
as many of them are illiterate.
All teams were missing gender training, both local and expatriate
and the organization did not put in place an specific policy that
would have facilitated the support and referral of vulnerable
cases and/or to coordinate with other organizations to ensure
the welfare of women and girls in their communities.
With regard to the positive impact of the intervention, it can
be said that the training of local staff has been a priority since
the beginning of the project, and the satisfaction of the workers
concerning this is reflected in their answers on the evaluation.
The trainings have not only been associated with topics related
to the work done in the ETC, but they have also been expanded
according to the demands made by the staff at the time to
organize them and carry them out.
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 11
TEST QUESTIONNAIRE
& REVISIONS
INTRODUCING
QUESTIONNAIRES IN
THE DATA BASE
STAKEHOLDERS
INTERVIEWS IN
MOYAMBA
FOCUS GROUP
DISCUSSIONS
GENDER TRAINING
PSS TEAM
X
X
GENDER TRAINING
MEDICAL TEAM
DATA ANALYSIS
16 - 31
STAFF INTERVIEWS
STAKEHOLDERS
INTERVIEWS IN
FREETOWN
1 - 15
16 - 30
NOVEMBER DECEMBER
1 - 15
1 - 15
16 - 31
16 - 30
DESIGN DOCUMENTS:
TOR, QUESTIONNAIRE,
CONSENT FORM
OCTOBER
1 - 15
SEPTEMBER
FINAL VERSION
Methodology
The evaluation used a mixed methodology of both quantitative
and qualitative data collection methods. Data collection was done
using desk review, surveys, informal interviews and Focus Groups
Discussions.
Desk review. It provided a full picture of the situation of the
country in terms of gender. The desk review examined issues
related to the circumstances of women in Sierra Leone before,
during and after the Ebola Outbreak, as well as the framework in
which the project took place, having in mind the laws and policies
regarding gender and the issues associated with public health
and its impact in the population, mainly in women and girls, that
could have been potentially taken into account when formulating
and while implementing the project. Literature about Ebola
outbreaks in other contexts was also reviewed, focusing mostly
on the impact of the disease in women and girls. Quantitative and
qualitative data were collected from the bibliography consulted.
Quantitative approaches. A survey (annex 1) was conducted
with the local staff working at the ETC; the total number of
employees at the time of the interview was 160 (50 women and
110 men) and of these, a stratified sample (once identified the
relevant stratums a random sampling is used to select a sufficient
number of subjects from each stratum) of 70 participated in it
(44% of total), 26 women (52% of total) and 44 men (40% of
total).
ADMIN
LOG
IPC
MALE
TOTAL STAFF
160
50
110
TOTAL INTERVIEWS
CARRIED OUT
70
26
44
44%
52%
40%
% OF THE TOTAL
POSITION
N INTER- FEMALE
VIEWS
HR/ADMIN
ASSIST.
LOG OUTREACH
100%
DRIVER
25%
LOG ASSISTANT
100%
COOK
% OF THE
TOTAL
100%
40%
COOK ASSISTANT 1
50%
LOGISTICS
ASSISTANT
100%
STOCK KEEPER
50%
BURIAL
MANAGER
100%
CLEANER LR
50%
CLEANER VLR
25%
UNDRESSER
45%
WASTE
MANAGER
70%
PLUMBER
ASSISTANT
15%
DRESSER
35%
HYGIENIST
17
15
50%
LAUNDRY
OFFICER
35%
NURSE AIDE
70%
CHO
100%
PSS
100%
CDO
100%
TOTAL
70
26
44
MEDICAL NURSES
PSS
MALE
65%
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 13
All the interviews were anonymous and the consent script (annex
2) was read before the start.
Qualitative approaches. A total of 4 Focus Group Discussions
(FGD) were held, 2 of them with 4 teachers that were working
before in the ETC and the other 2 with 10 members of the
psychosocial team (PSS), that were the only ones in direct contact
with the patients, their families and relatives inside and outside the
ETC as well as in touch with the communities affected.
The FGD were divided by male and female. Some of them were
held in local languages after asking the participants in which
language they felt more comfortable.
The PSS Team was also carrying out FGD in the affected
communities, and some of their findings have been used in the
content of the assessment.
Besides this, informal interviews with key informants, local and
international NGOs present in Moyamba and with the local
authorities were conducted.
Data collection and analysis. To carry out the survey an
assistant was hired for a period of 15 days. In a period of a
week, groups of four people were completing the questionnaire
in the same place but with space enough to keep privacy. As the
interviews were anonymous, the consent script was read instead
of written and signed, and any question that arose was solved
instantly.
The questions were written in English, but after seeing the
difficulties of some of the respondents to write in English, we
decided to allow them to do it in creole or in any local language,
and to translate the questionnaire afterwards.
The second week was used for data entry, after all the interviews
were finished.
Challenges encountered. In each section there is information
regarding the difficulties encountered during the data entry and
data analysis stage, if any.
Dissemination. This report is intended for broad dissemination
within the humanitarian community and its different forums of
coordination and information. It is not subject to any restriction but
should be properly cited if referred to.
GENDER CONTEXT
Beginning of the epidemic
Sierra Leones first Ebola case occurred in late May 2014, on the
border with Guinea. The first affected area was Kailahun district,
while the first case in Freetown was reported in mid July. The first
doctor dead was Dr. Shiekh Khan, the countrys only virologist,
who was infected while treating Ebola patients and died at the
treatment center in Kenema on 29 July.
Public health emergency was declared in Sierra Leone on 31 July
2014. Quarantine of houses with confirmed cases and outbreak
areas, restrictions on public meetings and gatherings, screening
of passengers at airports, active surveillance and house-to-house
searches were enforced. The government set aside 4th of August
as Ebola Day in order to inspect houses, trace contacts and
quarantine suspected cases.
By early August all districts, except Koinadugu in the north, had
confirmed cases. Throughout August and September several
Ebola Treatment Centers were planned in strategic locations
throughout the country by the UK Department for International
Development (DfID), to complement the already existing centers
run by Medecins Sans Frontieres and the Red Cross.
In SL health system, most of the activities rely on women, i.e.,
nursing, cleaning, laundry, etc. Traditional birth attendants
are women, meaning they were at high risk of exposure. Also
pregnant women were at high risk because of increased contact
with health services and health workers. Two of the three largest
outbreaks of Ebola involved transmission of the virus in maternity
settings, according to the World Health Organization.
Regarding family care, when a family member is sick and is
tended at home, women cook and serve food to the sick, clean
after them and wash their clothes. This role is extended to the
medical field, where women are mostly nurses and cleaners at
hospitals and do not get the same support and protection as
doctors, who are predominantly men.
Regarding family care, when a family member is sick and is
tended at home, women cook and serve food to the sick, clean
after them and wash their clothes. This role is extended to the
medical field, where women are mostly nurses and cleaners at
hospitals and do not get the same support and protection as
doctors, who are predominantly men.
Sierra Leone
By sex*
By age group
(per 100.000 population) (per 100.000 population)
Male
Female
Both sexes
All ages
Total
All ages
Total
years
years
15 - 44
45+
4.823
5.118
1.992
5.636
2.140
0 - 14
years
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 15
There are also some traditional practices linked with the spread of
the virus like levirate and burial rites36:
4. Social Pathways for Ebola Virus Disease in Rural Sierra Leone, and Some
Implications for Containment Paul Richards, Joseph Amara, Mariane C. Ferme,
Prince Kamara, Esther Mokuwa, Amara Idara Sheriff, Roland Suluku and Maarten
Voors. Ann M Powers, Editor.
5. https://data.hdx.rwlabs.org/dataset/ebola-treatment-centers/resource/e8a9fa595068-4d2d-855e-788c63d061e8
6. S2004 Population and Housing Census, Statistics Sierra Leone, www.statistics.sl
In the case of the toilet facilities, they were mixed. It seems that in
some ETCs theyve tried to separate them (i.e. Kissy) but nobody
placed signs specifying whether they were for men or women
therefore the measure was not effective and both used both toilets.
The first center with maternity ward was Kailahun (Msf), opened
in June/July 2014. In January 2015, MsF too, opened a center,
9. Ibid.
10. IASC (Inter-Agency Standing Committee), Reference Group for Gender in
Humanitarian Action: Humanitarian Crisis in West Africa (Ebola). Gender Alert:
February 2015.
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 17
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 19
Kissy, the first one with specialized care for pregnant women
infected by Ebola or suspected to be infected. The center had
different areas for suspected and confirmed cases. There were
several proposals in other MsF ETCs for a triage only for pregnant
women to avoid long waits for women with gynecological
problems, but none was carried out.
In Kenema, Red Cross launched the Pediatric Observation Unit
for non-positive children with their parents admitted or dead and
nowhere to go. Male and female survivors attended them.
In general, children admitted in the ETCs were mostly cared for by
women: survivors, patients or a relative; although in some cases
there were men, this was not the general trend.
Regarding the admission and treatment of patients according to
the Multi Sectorial Gender Impact Assessment:
In the case of Sierra Leone, women who were expectant or in
their menstrual cycle () at the time of their extraction from their
homes and referral to EVD holding centers were treated as if they
were confirmed cases of EVD (simply because of the bleeding).
This caused tremendous psychosocial anguish in the sense of
unjust suspicion form EVD.
As well as the fact of having mainly men in the Surveillance Team,
this degrading treatment of women did not help them to approach
the ETCs.
It is also known that there have been cases of sexual violence
in certain ETCs, as it was expressed in informal chats with key
informants and also shown in different assessments:
In the case of Sierra Leone, women who were expectant or in
their menstrual cycle () at the time of their extraction from their
homes and referral to EVD holding centers were treated as if they
were confirmed cases of EVD (simply because of the bleeding).
This caused tremendous psychosocial anguish in the sense of
unjust suspicion form EVD.43
12. Shamed and Blamed: Pregnant Girls Rights at Risk in Sierra Leone, Amnesty
International, 2015.
13. Sierra Leone 2013 Demographic and Health Survey-Key Findings, http://
dhsprogram.com/publications/publication-SR215-Summary-Reports-Key-Findings.
cfm
14. Childrens Ebola Recovery Assessment: Sierra Leone, Save the Children, UNICEF,
Plan, World Vision, March 2015.
11. Rapid Gender Assessment Report of the Ebola Response in Sierra Leones
OXFAM Operational Areas, Dr. Fatmatta Taqi, 12th January 2015.
15. A Mountain to Climb. Gender Based Violence and Girls Right to Education
in Sierra Leone, Defence for Children International, May 2015, http://www.
defenceforchildren.org/wp-content/uploads/2015/06/GBV-and-Girls-Right-toEducation-in-Sierra-Leone_May2015_EN.pdf
Pregnant Teens
Pregnant Teen
2013
2014
% Change
Ribbi
141
144
2,1
Fakunya
166
260
56,6
Dasse
126
94
(25,4)
Lower Banta
230
283
23,0
Upper Banta
74
126
70,3
Kamajie
35
48
37,1
Kowa
77
55
(28,6)
Kaiyamba
240
237
(1,3)
Kori
264
285
8,0
Bagruwa
90
115
27,8
Timdale
94
75
(20,2)
Kargboro
168
342
103,6
Kongbora
58
126
117,2
Bumpeh
164
234
42,7
TOTAL
1.927
2.424
25,8
2013
2014
2.000
1.500
1.000
500
0
Pregnant
Teen Girls
Pregnant
and Married
Pregnant
Out of School
Pregnant
& in School
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 21
Medical approach
As regarding many other infectious diseases, no specific or
appropriate treatment for female and male patients has been
studied during the Ebola outbreak. Clinical trials have included
only males, and in those including both males and females no
distinction was made between them in the analysis.48
Not only sociological and gender factors have not been taken into
account in the EVD, but also the biological differences between
women and men in the medical treatment.
Understanding the role gender plays in an Ebola epidemic is
crucial so that communication and intervention strategies can
be better targeted. Women play a major role as conduits of
information in their communities, and therefore they are being
enlisted as leaders in campaigns to spread awareness about the
disease.
16. Addressing sex and gender in epidemic-prone infectious diseases. WHO, 2007.
FINDINGS
Infrastructure
The aim is to analyze whether the Ebola Treatment Center in
Moyamba took into account the gender approach in its design,
if the spaces were outlined thinking that men and women will
occupy them and considering also, as far as possible, customs
and/or local taboos, which could be crucial when making a patient
feel more or less comfortable and seeking to avoid possible
situations of vulnerability for women and girls.
Moyamba ETC is divided into three main areas: White (or Very
Low Risk), Green (Low Risk) and Red (High Risk). While in the
first two sections the toilets along with the changing rooms were
gender friendly, that is, separated by sex, that was not the case in
the Red Zone.
In the High Risk area there were 6 big tents: Suspected (one tent),
Probable (two tents), Confirmed (two tents) and Convalescent
(one tent). All tents were mixed and so were the bathrooms.
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 23
Men 45-65
Staff working
in not culturally
apropiate jobs
NA
NO
YES
Woman 45-65
Male
Female
Lenguaje
Men 35-45
Woman 35-45
Staff of the
opposite sex
Men 25-35
Mixed Wards /
Little Privacy
Woman 25-35
Men 18-25
Mixed Toilets
Woman 18-25
0
05
10
15
20
05
10
15
20
YES
T
here were a lot of patients per tent (10), it should be reduced:
2 to 5
creens block the view while cleaning a patient but it is not
S
enough. Patients are confused and they move around.
T
o have a father and a daughter in the same ward, him half
naked Also a brother that sees sisters nakedness it is a
taboo
( Male patients) because of the seriousness of the virus, most
of them do behave abnormally and in such cases they pay no
privacy to women inside the ETC
NO
10
20
30
40
50
60
70
AWARENESS RAISING,
CASE DETECTION AND
TRANSFER TO THE ETC
The Social Mobilization Pillar was in charge of awareness of the
population on Ebola and health promotion. It is a key actor since
its main function is to sensitize and inform the community about
transmission modes of the disease, what to do if someone has
symptoms, and to inform about the work of the ETC.
There were 5 social mobilization groups per chiefdom, with a
DHMT supervisor and key role players involved (paramount chiefs,
traditional healers, etc.). These groups were not gender balanced
fromthe beginning of the epidemic and according to the key
informants interviewed women were afraid of Ebola, but little by
little they were trying to involve them.
There were different activities carried out to sensitize the
communities:
Radio programs and radio discussions.
own criers; in catchment villages, someone with a
T
microphone crying the key messages.
Recommendations:
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 25
17. From the date of opening to the date of closing as ETC, 31st March 2015.
Bagruwa
Kori
Lower Banta
(blank)
1
60
Ribbi
Moyamba City
Moyamba
Kongbora
Kargro
2
30
Kalyamba
FakumYa
Bumpeh
4
0
10
20
30
40
50
60
70
0%
Bagruwa
0%
Kori
0%
Lower Banta
0%
0%
(blank)
Ribbi
45%
Moyamba City
0%
Moyamba
0%
Kongbora
0%
Kargro
0%
Kalyamba
17%
FakumYa
Bumpeh
0%
25%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
8
6
4
2
0
0 05 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Age
14
45
40
12
Male
Female
40
35
Number of Cases
Number of Cases
10
8
6
4
30
25
25
20
15
10
2
0
5
0 05 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Age
6
<5y
9
5
6-17y
18-60y
>60y
Age
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 27
MALE
FEMALE
25,00%
40,48%
0%
10%
20%
30%
NEG (group)
40%
50%
60%
70%
80%
90%
100%
POS - POS
18. Childrens Ebola Recovery Assessment: Sierra Leone, Save the Children,
UNICEF, Plan, World Vision, March 2015
Shamed and Blamed: Pregnant Girls Rights at Risk in Sierra Leone, Amnesty
International, 2015
DISCHARGE
Hard work for female, i.e. doing the same work as men
en doing the work of women, i.e. laundry, assistant in
M
cooking and cleaning
As long as you are a patient you dont have any right
All admitted patients and their relatives had the possibility to
appeal to the psychosocial team, in charge of:
roviding psychosocial support for ETC patients and families
P
by taking care of the psychological health of patients admitted
in the ETC;
onducting patients family tracing contact and
C
communication; facilitating their visits to the ETC whenever
possible;
ddressing fears and worries of patients families regarding
A
Ebola and ensuring that families and communities got the
right information in a comprehensive way involving the state of
Ebola and questions regarding EVD.
Challenges encountered:
one of the expatriate doctors who were in Moyamba ETC at
N
the time of the investigation had worked with positive patients,
and they did not have the information to answer some of the
questions.
I t will be highly desirable to interview more patients in the
communities but this was not possible due to lack of time and
lack of a support team to do it.
o gender perspective at all in most of the staff, either local or
N
expatriate.
Recommendations:
Recruit gender sensitive staff and/or build their capacity on
gender issues: for privacy and protection of women and girls
and also to understand the importance of gender issues in
general and in emergency contexts in particular
o ensure that there is no loss of information by creating
T
appropriate protocols for transferring it to other expatriates
Flexibility to change the project strategy so it suits womens
needs
ake into account knowledge of local staff to improve the
T
treatment of patients
To value local knowledge
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 29
Challenges encountered:
18
16
12
Recommendations:
ecruit gender sensitive staff and/or build their capacity on
R
gender issues: for privacy and protection of women and girls
and also to understand the importance of gender issues in
general and in emergency contexts in particular
o monitor the conditions of women and girls once they
T
returned to their communities and to coordinate with other
organizations to ensure that the rights of women and girls are
not violated.
o recognize and compensate the unpaid effort of women
T
during the Ebola outbreak, taking care of sick members of their
families by valuating it socially and economically
Staff
At the time of the assessment, the local staff in the ETC were 160
people, 68% of them were men and 32% women: 110 men and
50 women. Interviews were a total of 70, 26 women and 44 men.
At the date of the opening, 16th December 2014, the local staff
were 240 people, 70% of them were men and 30% women: 170
men and 70 women.
Regarding the expatriates, since the beginning of the project
there have been 110 expatriates, 53 women and 57 men.
Figures here are much more compensated than in those of local
personnel.
EDUCATION
The level of education of the local staff varies depending on the
position they hold: in age range between 25-35 years there is the
largest number of people with university education, a majority of
them men. It should be noted that most workers have at least
secondary education, regardless of gender.
Primary
Secondary
College/Univerity
Other
14
10
8
6
4
2
0
MEN
WOMEN
18-25 years
MEN
WOMEN
25-35 years
MEN
WOMEN
35-45 years
MEN
Challenges encountered:
hort time frame to test the questionnaires, do the interviews
S
and to input the data.
Support team only available for a few days.
ecause of this there were up to 6 people in the same room
B
filling (individually) the questionnaires, which it is not ideal.
ome supervisors didnt want the participants to fill the
S
questionnaires in working hours, so the staff was extending
their workday to participate.
ome people were not confident answering/writing in English,
S
so they were answering in creole and later had to be translated
into English.
Some of the questions were too sensitive and others were not
properly formulated, so it is likely that the information in this
aspect could be biased or incomplete.
Recommendations:
Prioritize educated women rather than men because there are
fewer of them.
ry to ensure equal participation of women and men in all
T
teams.
Promote trainings and capacity building in all teams.
WOMEN
45-60 years
ORIGIN
30
25
70
60
15
50
10
40
30
BO
KENEMA
MOKOREWO
MORTHANKIL
YOYEMA
SEMBEHUN TOWN
SEMBEHUN
NYANDEHUN
MOYAMBA TOWN
MOSTINRGOR
10
KAIYAMBA
20
WATERLOO
MOYAMBA
MOYAMBA
This is not surprising given the ETC is located there, even if the
vacancies were advertised in the whole country and were open
for people from another districts as well. What is shocking is
when examining the chiefdoms and villages they are coming from
because a large part of the workers came from the same places:
70
45
60
40
35
50
30
40
25
30
20
15
20
10
5
10
FULLAH
KISSI
KONO
KONGBORA
LIMBA
KARGBORO
LOKO
KAIYAMBA
MANDINGO
FAKUNYA
SHERBRO
BAGRUWA
TEMNE
MENDE
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 31
FIGURE 23. H
OW DID YOU FIND OUT ABOUT THE JOB
IN THE ETC?
45
40
35
30
25
20
15
18
10
16
14
FRIENDS &
RELATIVES
RADIO
OTHERS
N/A
19. Shamed and Blamed: Pregnant Girls Rights at Risk in Sierra Leone, Amnesty
International, 2015
20. Sierra Leone 2013 Demographic and Health Survey-Key Findings, http://
dhsprogram.com/publications/publication-SR215-Summary-Reports-Key-Findings.
cfm
Single
Married
Widow/er
Divorced
Fiance
12
10
8
6
4
2
0
MEN
WOMEN
18-25 years
MEN
WOMEN
25-35 years
MEN
WOMEN
35-45 years
MEN
WOMEN
45-60 years
50
22,5
45
22
40
21,5
35
30
21
25
20,5
20
15
20
10
19,5
5
0
NO
YES
19
NO
YES
Most of the men who moved did it without family. Out of 22233, 19
left it behind while only 2 of the women did it. In all cases people
left to care for the families of the workers were mostly women:
in-law, mothers, sisters, wives... This clearly shows that men have
more power of decision over their lives: whether or not to work,
where and also it demonstrates that women in a relationship
have less agency234 than those single.
This can be directly related to the answer to the question, Are you
the head of household?, which, in other words can be the same
as Are you the one taking decisions at home?. We also see here
that mostly men exercise this role, being the difference bigger in
the age range between 25-35, and becoming equal in the age
range between 45-65 years old:
25
30
15
25
No
Yes
20
10
15
5
10
0
NO
YES
5
0
WOMEN
MEN
21. Out of 69 respondents 22 men and 4 women changed their location to work in
the ETC.
22. Ability for a person, or agent, to act for herself or himself. A person who is not
allowed to act for herself/himself is lacking an agency, or is said to have been denied
agency.
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 33
16
Yes
No
14
12
10
8
LEADERSHIP
2
0
MEN
WOMEN
18-25 years
MEN
WOMEN
25-35 years
MEN
WOMEN
MEN
35-45 years
WOMEN
45-65 years
12
10
8
25
4
20
2
0
15
FATHER
MOTHER
BROTHER
HUSBAND
WIFE
UNCLE
PARENTS
10
WOMEN
MEN
23. Out of 69 respondents 43 said their supervisors were expatriates, 25 said they
were both local and expatriates and only 1 said the supervisor was local.
24. At the time of the assessment out of 160 people 69 were IPC, only 12 of them
were women (17%) compared to 57 men (82%).
Challenges encountered:
hort time frame to test the questionnaires, do the interviews
S
and to introduce the data
20
18
Men
Women
16
14
12
10
8
6
4
Recommendations:
ADVOCATE
FOR WOMEN
BACK TO MY
PREVIOUS JOB
START A
BUSSINESS
DO MORE
TRAININGS
FIND A
NEW JOB
CONTINUE
STUDYNG
USE OF TIME
There are some activities that are marked by the employees as
done with a high frequency such as cleaning, cooking, doing the
laundry, ironing, taking care of children and praying. The time
taken to perform them varies between men and women, but
women spend many more hours in most of them.
We have to think about the already existing burden that women
have when we talk about house cores and other work they do
without being paid for. If we add the ETC duties, most of them
see their workload multiplied. Only one of the respondents said
she had hired a caretaker.
A greater number of staff said their daily activities had changed
since they work in the ETC:
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 35
Women
Men
Women
30
Men
70
25
60
20
50
40
15
30
10
20
5
0
10
NO
YES
Women
Men
35%
30%
25%
20%
15%
10%
5%
0%
Challenges encountered:
Short time frame to test the questionnaires, do the interviews
and to introduce the data
Support team only available for few days
ecause of this there were up to 6 people in the same room
B
filling (individually) the questionnaires, which it is not ideal
ome supervisors didnt want the participants to fill the
S
questionnaires during working hours, so they had to extend
their workday to participate
ome people were not confident answering/writing in English,
S
so they were answering in creole and the answers later
translated into English
Recommendations:
FIGURE 37. D
ECISION MAKING, REGARDING THE
INCOMES, AT HOME LEVEL DISAGGREGATED
BY SEX AND AGE (WOMEN)
9
18-25
25-35
35-45
45-65
8
7
6
5
4
3
Women
18
Men
1
0
16
ME
BOTH
OTHER
N/A
14
12
10
12
8
6
18-25
25-35
35-45
45-65
10
4
2
0
ME
BOTH
OTHER
N/A
ME
BOTH
OTHER
N/A
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 37
25
40
Women
20
Men
35
15
30
10
25
20
15
10
NO
FURNITURE
HOUSE RENT
FARMING
ENTERTAINMENT
HOUSE CONSTRUCTION
CLOTHING
FAMILY SUPPORT
INVESTMENTS
MEDICATION
FEEDING
SCHOOL FEES
For both respondents, men and women, most of the priorities are
related with family wellbeing and family support, although in focus
groups many respondents expressed their concern about the
economic expectations their families and relatives have now that
they have a good income every month. This can be better seen in
the following graphics of improvements and challenges faced by
the staff due to their work in the ETC:
10
4
29. Out of 69 respondents, 27 females, 42 males
30. 14 out of 35
N/A
5
0
YES
31. 2 out of 35
YES
NO
N/A
32. 3 out of 35
30
Women
Men
25
20
15
10
STATUS IMPROVEMENT
MAKING FRIENDS
LEADERSHIP EXPERIENCE
DIGNITY
PROFESSIONAL EXPERIENCE
ECONOMIC IMPROVEMENT
CAREER IMPROVEMENTS
NEW SKILLS
14
Women
Men
12
10
8
Some of the questions were too sensitive and others were not
properly formulated, so it is likely that the information in this
aspect is biased/incomplete
4
2
ABUSES BY LOCALS
ABUSES BY EXPATS
TRANSPORTATION TO ETC
PRICES INCREASED
CHLORINE
PPE
DISCRIMINATION
STIGMA
FREQUENT CHANGE OF
INCREASED EXPENDITURE
Recommendations:
FINANCIAL EXPECTATIONS
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 39
IMPACT OF WORKING
IN AN ETC
Women
20
15
35
10
Women
Men
Men
30
25
0
20
YES
NO
N/A
15
10
40
35
0
YES
NO
N/A
Women
Men
30
25
20
15
10
5
0
YES
NO
N/A
The only woman who answered affirmatively said she was not
telling it to anybody, but the two men said they told it to someone
they trusted.
It has to be pointed out that the question was not formulated
correctly as it was intended to refer to sexual abuse, sexual
harassment and sexual violence; instead it turned out to be
confusing, as shown by the answers given by respondents to the
question about possible measures that the organization should
take to avoid these situations:
To counsel their workers on management skills
have a special mediator team for that. To regularly call
To
meetings to know the difference and find a solution for it
put the right man in the right place and talk to position
To
holders to know how to talk to their local staff
Therefore, after analyzing the responses to the questionnaires
and the focus group discussions, it was clear that they referred to
situations of abuse of power related to supervisors and that had
nothing to do with sexual violence.
In the focus group discussions, men stated they have realized
women feel uncomfortable when standing up in front of them
in the queue to pick up food because they think men will touch
them. This is a good example of how widespread is the abuse
and harassment that women are subjected to, although it has not
been reflected in the responses given in the survey. Again, as it is
an extremely sensitive subject, a specific study may be needed
for this if the subject is to be analyzed in depth.
Challenges encountered:
hort time frame to test the questionnaires, do the interviews
S
and to introduce the data
Support team only available for few days
ecause of this there were up to 6 people in the same room
B
filling (individually) the questionnaires, which it is not ideal
ome supervisors didnt want the participants to fill the
S
questionnaires in working hours, so the staff had to extend their
workday to participate
ome people were not confident answering/writing in English,
S
so they were answering in creole, and the answers later
translated into English
Some of the questions were too sensitive and others were not
properly formulated, so it is likely that the information in this
aspect is biased/incomplete
Recommendations:
nsure there is a protocol to support workers who are victims
E
of stigma or rejection
o put in place a specific protocol for sexual harassment,
T
sexual violence or sexual abuse inside the ETC
Create a trusted figure to do the work of mediation in the teams
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 41
CONCLUSIONS
The Ebola epidemic that has devastated Guinea, Liberia and
Sierra Leone has left in the last one a total of 14,123 cases and
3,955 deaths. According to WHO the number of women affected
exceeds 5.00033:
TABLE 6. CONFIRMED, PROBABLE AND SUSPECTED
EBOLA CASES IN SIERRA LEONE34
COUNTRY
CASE
DEFINITION
CUMULATIVE
CASES
CASES IN
CUMULATIVE
PAST 21 DAYS DEATH
SIERRA
LEONE
CONFIRMED
8.704
3.589
PROBABLE
287
208
SUSPECTED
5.131
158
TOTAL
14.122
3.955
CONFIRMED
During the last few weeks, two new cases of women infected with
the virus in Sierra Leone have been confirmed, one deceased and
the other infected after caring for the first one.
As it can be extracted from the data and documentation referred
to throughout the document, the response to the epidemic in
Sierra Leone has been blind to gender.
The Ebola outbreak in West Africa has been considered a Public
Health Emergency of International Concern, representing a
health risk not only to neighbour countries, but worldwide. All
stakeholder agree in highlight that the International response
came late; in August 2014 already there were 1427 deceased
people and MSF was nearly the only Organization dealing with
it.35 The late response, the high mortality and the risk of infectious
have been key factors in prioritizing the health approach of the
outbreak. However, other issues of great importance like the
questioning of traditional roles played by men and women have
been put aside. These roles affect their exposure to the virus and
increase the risk of infection and the severity of the illness.
33. Wsee Table 3. http://apps.who.int/ebola/current-situation/ebola-situation-report23-september-2015 Population figures are based on estimates from the United
Nations Department of Economic and Social Affairs. These numbers are subject to
change due to ongoing reclassification, retrospective investigation and availability
of laboratory results. *Excludes cases for which data on sex are not available.
Excludes cases for which data on age are not available. Data are until 9 May 2015.
34. http://apps.who.int/ebola/current-situation/ebola-situation-report-20january-2016 Sierra Leone was declared free of Ebola virus transmission in the
human population on 7 November 2015, and entered a 90-day period of heightened
surveillance. On 14 January, 68 days into the 90-day surveillance period, new
confirmed cases of EVD were reported in Sierra Leone after a post-mortem swab
collected from a deceased 22-year-old woman tested positive for Ebola virus. The
woman died on 12 January at her family home in the town of Magburaka, Tonkolili
district, and received an unsafe burial.
35. http://www.msf.org/article/ebola-failures-international-outbreak-response
ETCs
Treatment centres, meanwhile, lacked any gender sensitivity,
except those exclusively dedicated to maternity in which there
were only women. Women were not included in the design and
construction of the ETCs, and once opened, despite the urgency
of the epidemic, local knowledge could have been taken into
account.
Such knowledge, if applied, would have shown how to adapt the
existing structures, so that they were as respectful as possible
towards sensitive issues such as nudity or vulnerability to the
disease of people of the opposite sex, that when ignored have
generated psychological problems in many of the women who
have survived Ebola.36
36. Report of the Multi Sectoral Impact Assessment of Gender Dimensions of the
Ebola Virus Disease (EVD) in Sierra Leone, Ministry of Social Welfare, Gender and
Childrens Affairs, UN Women, Oxfam, Statistics of Sierra Leone, December 2014
Regarding the construction of the ETC, there was not much room
to propose changes in the infrastructure, although the responsible
for the realization were asked to include, for instance, separate
toilets, which was not possible. However, it must be highlighted
the importance of sanitary facilities separated by sex, to respect
privacy and to prevent abuse or violence against women.
Mdicos del Mundo, on the other hand, would have had a great
opportunity to alleviate the negative effects the disease has
on women. However, patterns that contribute to deepen the
structural differences between genders, with negative effects for
women, have been repeated.
FEMALE STAFF
Concerning the demand both from the patients and workers to
treat same-sex people, it has been difficult because most of the
health workers were women; nursing is a profession related with
care, and therefore is highly feminized.
However, apart from the female workers of the medical team, the
vast majority of the local staff of the centre were men. This may
be due to the difficulty in finding qualified female staff, but the
numerical differences were excessive, especially in teams like IPC,
This has led to perpetuate traditional roles: women dedicated
to caring (nursing, psychosocial, laundry, kitchen...) and men to
those which require more technical skills or that are socially best
rated (IPC, logistics, administration, drivers...).
CONCILIATION MEASURES
The evaluation results show that the burden of women has
doubled since having a fixed monthly income has not stop them
to take care of household chores, but continue to carry them
out at their leisure time. The implementation of a conciliation
measures policy would have facilitated the situation of single
women in combining work and family and most likely the number
of female workers had been higher.
GENDER AWARENESS
Regarding gender and sexual based violence, no protocols were
put in place, neither for workers nor for patients. Although no
cases have been reported inside the centre, we have knowledge
that the psychosocial team knew and took care of these
situations that occurred within the community, but did so in an
informal way leaving structural violence in the private sphere.
This reality could have been mitigated if all staff, in particular the
psychosocial team have had some capacity building regarding
gender and sexual based violence.
CAPACITY BUILDING
With regard to the positive impact of the intervention, it can be
said that the training of local staff has been a priority since the
beginning of the project, and the satisfaction of the workers
concerning this is reflected in their answers on the evaluation.
The trainings have not only been associated with topics related
to the work done in the ETC, but they have also been expanded
according to the demands made by the staff at the time to
organize them and carry them out.
All teams were missing gender training, both local and expatriate,
which has become a deficiency and insensitivity to these issues
that has undermined the autonomy and the right to health of
women before, during and after the epidemic.
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 43
RECOMMENDATIONS
Infrastructure
ake into account anthropological point of view when designing
T
Ebola Treatment Centres and any infectious disease intervention
(separate ablutions and wards in all the zones: white, green and
red)
DISCHARGE
o have gender sensitive staff: for privacy and protection
T
of women and girls and also to understand the importance
of gender issues in general and in emergency contexts in
particular
o monitor the conditions of women and girls once they return
T
to their communities and to coordinate with other organizations
to ensure that the rights of women and girls are not violated
o recognize and compensate the unpaid effort of women
T
taking care of sick members of their families during the EVD
outbreak
Staff
LEADERSHIP
EDUCATION
rioritize educated women rather than men because there are
P
fewer of them
ry to ensure equal participation of women and men in all
T
teams
Promote trainings and capacity building in all teams
USE OF TIME
To ensure measures designed to reconcile family and working
life
ORIGIN
ake sure that the means used to announce jobs vacancies
M
reach women of all the communities in the district by involving
womens organizations and Social Mobilization Pillar in the
dissemination of the offers
Try to ensure equal participation of women and men in all
teams
Guarantee diversity (of origin, religious and ethnic) between
ETC personnel
Gender Evaluation of Doctors of the World and Mdicos del Mundo Ebola response in Moyamba Ebola Treatment Center Project I 45
References
Amnesty International, Shamed and Blamed: Pregnant Girls
Rights at Risk in Sierra Leone, 2015
Defence for Children International, A Mountain to Climb.
Gender Based Violence and Girls Right to Education in Sierra
Leone, May 2015, http://www.defenceforchildren.org/wpcontent/uploads/2015/06/GBV-and-Girls-Right-to-Educationin-Sierra-Leone_May2015_EN.pdf
Demographic and Health Survey-Key Findings, Sierra Leone
2013, http://dhsprogram.com/publications/publication-SR215Summary-Reports-Key-Findings.cfm
Ebola Treatment Centers Database, https://data.hdx.rwlabs.
org/dataset/ebola-treatment-centers/resource/e8a9fa59-50684d2d-855e-788c63d061e8
Ministry of Social Welfare, Gender and Childrens Affairs, UN
Women, Oxfam, Statistics of Sierra Leone, diciembre 2014,
Report of the Muti Sectoral Impact Assessment of Gender
Dimensions of the Ebola Virus Disease (EVD) in Sierra Leone
Richards, Paul, Amara, Joseph, Ferme, Mariane c., Kamara,
Prince, Mokuwa, Esther,Idara Sheriff, Amara, Suluku, Roland,
Voors, Marteen, Powers, Ann M., Social Pathways for Ebola
Virus Disease in Rural Sierra Leone, and Some Implications for
Containment
Save the Children, UNICEF, Plan, World Vision, Childrens Ebola
Recovery Assessment: Sierra Leone, March 2015
TAQI, Dr. Fatmatta, Rapid Gender Assessment Report of the
Ebola Response in Sierra Leones OXFAM Operational Areas,
12th January 2015
UNDP, Human Development Report 2015. Work for Human
Development. http://report.hdr.undp.org
WHO, Addressing sex and gender in epidemic-prone infectious
diseases, 2007
WHO, Ebola Situation Report, 20 enero 2016 http://apps.
who.int/ebola/current-situation/ebola-situation-report-20january-2016
WHO, Ebola Situation Report, 23 septiembre 2015, http://
apps.who.int/ebola/current-situation/ebola-situation-report-23september-2015
Annexes
ANNEX 1. ToR Gender Evaluation Ebola Response Dotw/
Mdicos del Mundo (MdM) in Moyamba ETC, Sierra
Leone
ANNEX 2. Consent Script
ANNEX 3. Evaluation Form
ANNEX 4. Surveillance Team Triage Form
ANNEX 5. Moyamba ETC Triage Form
ANNEX 6. Medical Team Gender Workshop
ANNEX 7. PSS Team Gender Workshop